nearest emergency facility.
physicians to the injured employee.
- The incident report is the injured employee’s statement of what happened. Have the injured employee
completethis form and keep a copy of this document for your records. Email the completed form to
the HR Office, firstname.lastname@example.org or email@example.com
- This form explains the employee’s rights under the Pennsylvania workers’ compensation
law that must be signed by employees at the time of injury.
- This form also includes the list of panel physicians selected by the employer.
- Provide a signed copy of the forms to the injured employee and to the HR office.
- This form authorizes BrickStreet Insurance to request medical records related to the injured
- Have the injured employee take this form to his/her treating physician, which will include any